Form 1126 "Affidavit to Amend Mississippi Certificate of Live Birth" - Mississippi

What Is Form 1126?

This is a legal form that was released by the Mississippi Department of Health - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 13, 2018;
  • The latest edition provided by the Mississippi Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 1126 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Health.

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Download Form 1126 "Affidavit to Amend Mississippi Certificate of Live Birth" - Mississippi

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Office   o f   V ital   R ecords   &   S tatistics  
 
AFFIDAVIT   T O   A MEND   M ISSISSIPPI   C ERTIFICATE   O F   L IVE   B IRTH  
(Read   i nstruction   o n   n ext   p age   b efore   c ompleting   t his   f orm)  
FULL   N AME   A T   B IRTH:  
DATE   O F   B IRTH:  
COUNTY   O F   B IRTH:  
Item   T o   B e   C orrected  
Incorrect   I nformation  
Correct   I nformation  
 
 
 
 
 
 
 
 
 
 
 
 
Name   o f   S ignatory:  
Name   o f   S ignatory:  
Signature:  
Signature:  
_________________________________________  
_________________________________________  
 
 
Sworn   t o   a nd   s ubscribed   b efore   m e   t his   t he  
Sworn   t o   a nd   s ubscribed   b efore   m e   t his   t he  
______   d ay   _ ___________________,   2 0________  
_______   d ay   _ __________________,   2 0________  
 
 
Signature   o f   N otary:  
Signature   o f   N otary:  
 
 
_________________________________________  
_________________________________________  
 
 
My   C ommission   E xpires:_____________________  
My   C ommission   E xpires:_____________________  
 
 
The   f orm   m ust   b e   r eturned   t o   t he   O ffice   o f   V ital   R ecords,   a long   w ith   a ny   r equired   d ocumentation   a nd   r equired   f ee.     A ll  
signatures   m ust   b e   t he   o riginal   s ignature   a nd   n o   c opies   w ill   b e   a ccepted.  
Fee   i s   $ 28.00,   i ncludes   o ne   c ertified   c opy   o f   t he   a mended   r ecord.     A dditional   c opies   o f   t he   a mended   r ecord   a re   $ 6.00  
each   w hen   o rdered   a t   t he   s ame   t ime   f or   t he   s ame   p erson.  
Acceptable   d ocumentation   c an   b e   o ne   o f   t he   f ollowing.     T he   d ocument   m ust   s how   t he   n ame   a s   y ou   w ant   i t,   y our   a ge   o r  
date   o f   b irth.     T he   d ocument   m ust   b e   5   y ears   o ld   o r   o lder   a nd   n ot   b e   r ecently   i ssued.  
Physician’s   R ecord   –   C urrent   o r   f ormer   p hysician  
School   R ecord   –   H igh   S chool   t ranscript,   E lementary   s chool   r ecord   o r   r ecord   f rom   f irst   s chool   a ttended  
US   P assport   –   m ust   h ave   b een   i ssued   a t   l east   5   y ears   a go  
Old   D river’s   L icense   –   m ust   h ave   b een   i ssued   a t   l east   5   y ears   a go  
Military   D ischarge   R ecord   –   F orm   D D214  
Immunization   R ecord   –   f rom   p hysician   o r   c ounty   h ealth   d epartment  
Child’s   b irth   c ertificate   –   m ust   s how   c orrect   n ame   a nd   d ate   o f   b irth   o r   a ge  
 
Mississippi   S tate   D epartment   o f   H ealth                                                                                                           R evised   1 2/13/18    
 
 
                    F orm   1 126  
 
 
 
 
Office   o f   V ital   R ecords   &   S tatistics  
 
AFFIDAVIT   T O   A MEND   M ISSISSIPPI   C ERTIFICATE   O F   L IVE   B IRTH  
(Read   i nstruction   o n   n ext   p age   b efore   c ompleting   t his   f orm)  
FULL   N AME   A T   B IRTH:  
DATE   O F   B IRTH:  
COUNTY   O F   B IRTH:  
Item   T o   B e   C orrected  
Incorrect   I nformation  
Correct   I nformation  
 
 
 
 
 
 
 
 
 
 
 
 
Name   o f   S ignatory:  
Name   o f   S ignatory:  
Signature:  
Signature:  
_________________________________________  
_________________________________________  
 
 
Sworn   t o   a nd   s ubscribed   b efore   m e   t his   t he  
Sworn   t o   a nd   s ubscribed   b efore   m e   t his   t he  
______   d ay   _ ___________________,   2 0________  
_______   d ay   _ __________________,   2 0________  
 
 
Signature   o f   N otary:  
Signature   o f   N otary:  
 
 
_________________________________________  
_________________________________________  
 
 
My   C ommission   E xpires:_____________________  
My   C ommission   E xpires:_____________________  
 
 
The   f orm   m ust   b e   r eturned   t o   t he   O ffice   o f   V ital   R ecords,   a long   w ith   a ny   r equired   d ocumentation   a nd   r equired   f ee.     A ll  
signatures   m ust   b e   t he   o riginal   s ignature   a nd   n o   c opies   w ill   b e   a ccepted.  
Fee   i s   $ 28.00,   i ncludes   o ne   c ertified   c opy   o f   t he   a mended   r ecord.     A dditional   c opies   o f   t he   a mended   r ecord   a re   $ 6.00  
each   w hen   o rdered   a t   t he   s ame   t ime   f or   t he   s ame   p erson.  
Acceptable   d ocumentation   c an   b e   o ne   o f   t he   f ollowing.     T he   d ocument   m ust   s how   t he   n ame   a s   y ou   w ant   i t,   y our   a ge   o r  
date   o f   b irth.     T he   d ocument   m ust   b e   5   y ears   o ld   o r   o lder   a nd   n ot   b e   r ecently   i ssued.  
Physician’s   R ecord   –   C urrent   o r   f ormer   p hysician  
School   R ecord   –   H igh   S chool   t ranscript,   E lementary   s chool   r ecord   o r   r ecord   f rom   f irst   s chool   a ttended  
US   P assport   –   m ust   h ave   b een   i ssued   a t   l east   5   y ears   a go  
Old   D river’s   L icense   –   m ust   h ave   b een   i ssued   a t   l east   5   y ears   a go  
Military   D ischarge   R ecord   –   F orm   D D214  
Immunization   R ecord   –   f rom   p hysician   o r   c ounty   h ealth   d epartment  
Child’s   b irth   c ertificate   –   m ust   s how   c orrect   n ame   a nd   d ate   o f   b irth   o r   a ge  
 
Mississippi   S tate   D epartment   o f   H ealth                                                                                                           R evised   1 2/13/18    
 
 
                    F orm   1 126  
 
 
INSTRUCTIONS   –   R EAD   C AREFULLY  
 
The   s ubmission   o f   t his   f orm   d oes   n ot   g uarantee   a n   a mendment   w ill   b e   p rocessed   o n   t he   b irth   c ertificate.     A ll  
requirements   m ust   b e   m et   a nd   a ll   d ocumentation   m ust   f ollow   t he   r equirements   o f   t his   o ffice.     I f   t he   f orm,   d ocuments  
or   f ee   d oes   n ot   m eet   t he   r equirements   s et   f orth   b y   t his   o ffice,   a ll   i tems   w ill   b e   r eturned   t o   y ou   w ith   a n   e xplanation   a s   t o  
why   a nd   w hat   a ctions   m ust   b e   t aken   t o   g et   t he   r ecord   a mended.  
 
Section   4 1-­‐57-­‐21   o f   t he   M ississippi   c ode   o f   1 972,   p rovides   t hat   “ Where   t here   h as   b een   a   b ona   f ide   e ffort   t o   r egister   a  
birth   a nd   t he   c ertificate   t hereof   o n   f ile   w ith   t he   o ffice   o f   V ital   R ecords   d oes   n ot   d ivulge   a ll   o f   t he   i nformation   r equired  
by   s aid   c ertificate,   o r   s uch   c ertificate   c ontains   t he   i ncorrect   f irst   n ame,   m iddle   n ame,   o r   s ex,   t hen   t he   S tate   R egistrar   o f  
Vital   R ecords   R egistration   m ay,   i n   h is   d iscretion,   c orrect   s uch   c ertificate   u pon   a ffidavit   o f   t wo   ( 2)   r eputable   p ersons   ( you  
and   o ne   o ther)   h aving   p ersonal   k nowledge   o f   t he   f acts   i n   r elation   t hereto.     “ Documentation   m ay   b e   r equired   a t   t he  
discretion   o f   t hat   S tate   R egistrar.”     A ll   o ther   a lterations   s hall   b e   m ade   a s   p rovided   i n   S ection   4 1-­‐57-­‐23.”     “ Anyone   g iving  
false   i nformation   i n   s uch   a ffidavit   s hall   b e   s ubject   t o   t he   p enalties   o f   p erjury.”  
1. Complete   t he   t op   p ortion   o f   t he   a ffidavit.     T his   a ffidavit   w ill   b e   a ttached   t o   t he   o riginal   b irth   r ecord   t hus  
becoming   p art   o f   t he   b irth   r ecord.     P lease   u se   b lack   i nk   a nd   p rint   c learly.  
a. FULL   N AME   A T   B IRTH   –   E nter   t he   n ame   a s   i t   a ppears   o n   t he   b irth   c ertificate.  
b. DATE   O F   B IRTH   –   E nter   t he   d ate   o f   b irth   a s   i t   a ppears   o n   t he   b irth   c ertificate.  
c. COUNTY   O F   B IRTH   –   E nter   t he   c ounty   w here   t he   b irth   o ccurred.  
d. Item   t o   b e   c orrected   –   L ist   t he   i tem(s)   i n   e rror.     ( Example:   C hild’s   f irst   n ame,   C hild’s   m iddle   n ame,  
Mother’s   f irst   n ame,   F ather’s   f irst   n ame.)  
e. Incorrect   I nformation   –   E nter   i nformation   a s   i t   a ppears   o n   t he   b irth   c ertificate.  
f.
Correct   I nformation   –   E nter   t he   i nformation   a s   i t   s hould   b e.  
2. The   a ffidavit   m ust   b e   s igned   b y   r egistrant   a nd   o ne   r eputable   h aving   k nowledge   o f   t he   b irth   o r   i nformation   i n   t he  
presence   o f   a   n otary   p ublic.     I f   t he   p erson   r equesting   t he   a mendment   i s   u nder   t he   a ge   o f   1 8,   a   p arent   o r   l egal  
guardian   ( with   p roof   o f   g uardianship)   m ust   s ign   i n   a ddition   t o   o ne   r eputable   p erson   h aving   k nowledge   o f   t he  
event(s).  
3. The   f ee   f or   a n   a mendment   o r   c orrection   t o   a   M ississippi   V ital   R ecord   i s   $ 28.00.     D O   N OT   S END   C ASH.     W e   a ccept  
money   o rders,   p ersonal   c hecks   a nd   c ashier   c hecks.  
 
MAIL   T HE   A FFIDAVIT,   A NY   R EQUIRED   D OCUMENTATION   A ND   F EE   T O:  
MS   V ITAL   R ECORDS  
P   O   B OX   1 700  
JACKSON,   M S     3 9215  
ATTN:   C ORRECTION   U NIT  
 
 
 
 
 
 
 
 
Mississippi   S tate   D epartment   o f   H ealth                                                                                                           R evised   1 2/13/18    
 
 
                    F orm   1 126  
 
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